Peer-Review ReportAugmented Reality-Assisted Bypass Surgery: Embracing Minimal Invasiveness
Introduction
Although a useful tool in the neurosurgeon's armamentarium, extracranial-to-intracranial (EC-IC) bypass surgery remains a demanding procedure in which the final result is dependent on the successful realization of several consecutive steps 8, 11, 19, 32, 34, 43. To begin with, the donor branch of the superior temporal artery (STA) (37) or the occipital artery (OA) (17) is harvested, after localization through manual palpation, with a Doppler ultrasound device or an angiographic road-map; a craniotomy is then performed centered over the region of interest. A suitable recipient artery is chosen (9), among those exposed, based on the vessel's caliber, its superficial localization, and the absence of significant branching; the donor and recipient vessels are then prepared, and only once all these steps are accomplished can the surgeon address the task of performing the anastomosis.
This lengthy procedure presents pitfalls 31, 34. Inadequate localization can result in damage to donor vessels during dissection, because of their variable anatomy and tortuous trajectory 1, 11, 17, 22, 23, 35. If the damage incurred precludes the vessel's use for anastomosis, a salvage operation must be performed, by harvesting a radial artery or a saphenous vein, which further lengthens the procedure; in the worst of cases, surgery may have to be aborted altogether. Furthermore, although current trends advocate minimal invasiveness (12), the craniotomy during theses procedures is usually performed large enough to increase the chance of finding a suitable recipient artery. In addition, the surgeon may have difficulty in intraoperatively identifying the optimal vessel that was chosen for anastomosis on preoperative angiography.
Augmented reality technology has found applications in surgery, where virtual images from preoperative imaging studies (e.g., computed tomography [CT] or magnetic resonance imaging [MRI]) are overlaid on the operating site for image-guidance (38). Various setups that use augmented reality have been reported for neurosurgical procedures 4, 5, 6, 14, 15, 18, 20, 21, 26, 27, 28, 29, 39, 40), although none, to our knowledge, has explored its use for bypass surgery, where this technology might be helpful in overcoming the aforementioned difficulties.
We have previously developed a standard operating procedure, based on augmented reality with image injection into the microscope's eyepiece (5), and we sought to evaluate the usefulness of this setup during EC-IC bypass procedures.
Section snippets
Methods
The augmented reality-based operating procedure we used has been detailed in a previous publication (5). For the purpose of this article, we briefly describe the procedure while emphasizing its specificities when applied to EC-IC bypass procedures.
Usefulness of Augmented Reality
A total of 5 STA-MCA bypasses and 1 OA-PICA bypass was performed. The described setup allowed precise localization of the donor vessels in all cases; it helped to guide the skin incision and helped during harvesting by following the vessel and anticipating its course. It was particularly appreciated during dissection of the OA, because of its sinuous trajectory (Figure 2A–B). No damage incurred to the donor vessels. Table 1 summarizes for each case the comparison of augmented reality-assisted
Discussion
EC-IC bypasses can prove to be arduous procedures, performed in a step-by-step manner, from the harvesting of donor vessels, performing the craniotomy, selecting a recipient vessel, to the actual anastomosis. The presented setup based on augmented reality has the potential to help during these operations. Any novel method, however, has to fulfill 2 conditions: First, the help it provides should be superior to that already given by currently used techniques; second, it should not disrupt the
Conclusion
Augmented reality has evolved in the present setup to be a useful and easily applied tool during EC-IC bypass surgery. It can help to harvest donor vessels through their precise localization, to tailor craniotomies to the needs of a given patient, and to identify preoperatively selected recipient vessels for anastomosis. Although its impact on patient outcome is not yet quantifiable, it appears as a helpful technique for these procedures and is in accordance with the current trend of minimal
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Conflict of interest statement: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.